Inspection on 06/02/08 for 37 Redgate Court

This inspection was carried out on 6th February 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

37 Redgate Court 20/03/07

37 Redgate Court 03/02/06

37 Redgate Court 08/09/05

37 Redgate Court 17/03/05

37 Redgate Court 20/07/04

37 Redgate Court 05/03/04

Similar services:

Coopers Mill Ltd

Pocklington House

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Redgate Court (37) Peterborough PE1 4XZ Lead Inspector Shirley Christopher Unannounced Inspection 6th February 2008 10:30 Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Redgate Court (37) Address Peterborough PE1 4XZ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01733 314559 F/P 01733 314559 sally.porteious@sense.org.uk www.sense.org.uk Sense, The National Deafblind and Rubella Association Sally Porteious Care Home 6 Category(ies) of Learning disability (6), Sensory impairment (6) registration, with number of places Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Learning Disability only in association with Sensory Impairment Date of last inspection 20th March 2007 Brief Description of the Service: 37 Redgate Court consists of a purpose built property, situated on a residential estate on the north eastern edge of Peterborough. The home is a two-storey, semi-detached property in an accommodation complex catering for adults with learning disability. It is owned by Sense East and provides care and support for up to 6 people with learning disability, associated with sensory impairment. The home has 6 individual bedrooms; 4 on the upper floor and 2 on the ground floor. There is a bathroom with shower and toilet on both floors, an open planned lounge dining area and a kitchen. A conservatory leads off the lounge area to the large, well maintained garden, which is shared with the adjoining house. The home is within walking distance of local shops, pubs, post-office and public transport. Peterborough city centre is about 5 miles away and is easily accessed by public transport. Weekly fees range from £1595 to £2020. Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. We, The Commission Of Social Care Inspection carried out an unannounced inspection of Redgate Court (37) on 6 February 2008, using the Commission for Social Care inspection (CSCI)’s methodology. We visited the home, spoke with several staff and checked some of the records. The manager was in charge on the day of the inspection. Several care staff were on duty and one resident was at home. Other residents were out for the day, participating in various activities Surveys were sent out to residents, relatives and care staff before the inspection. We received 9 responses in total. The feedback was good and indicated that the service were meeting the needs of residents. Their comments are included in this report. The manager completed an Annual Quality Assurance Assessment, (AQAA) which was returned to us before the inspection. This contained detailed information about how the home is managed. What its strengths and weaknesses are and where it has and needs to improve. A copy of the services latest self-assessment report was made available. What the service does well: What has improved since the last inspection? Shortfalls in staffing have been addressed. The manager stated that staff morale has improved and there is less dependency on agency staff. Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People using the service have the information that they need to choose if the home is where they want to live. EVIDENCE: No one has recently moved into the home. The manager said that the statement of purpose has recently been updated. The Deputy Regional Director stated in her response to the draft report that ‘The service user guide was readily available in pictorial format, only one other service user at this house would be able to comprehend the service user guide and the complaints procedure, and that person’s preferred format would be Braille. SENSE has the ability to provide the guide in Braille immediately for any service user requesting it. However, SENSE additionally puts in place a mentoring and support mechanism which is built into the timetable at the Hampton Resource Centre, this offers our service users the opportunity to discuss anything that concerns them about their home and support. Should any issues be raised via this system, the information would be immediately actioned to the service user’s home and the leaflet in appropriate format would Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 9 be supplied Additionally the deaf blind person would be assisted in their preferred communication method to take their issue forward.’ The service user guide should incorporate the views of the people using the service. The Deputy Regional Director stated ‘contracts initiated by the funding organisation are held centrally for all of our service users. However 37 Redgate now has obtained a copy of all the service users contracts and all held with the appropriate care plans. The manager is aware of the need to make this information accessible for all our service users. However due to the complexity of the information contained within these documents this is not easily resolved, nevertheless the House Manager continues to work towards this. The home is able to meet the needs of the people using the service. This is achieved by good recruitment procedures, structured induction and support. Staff training can be linked to the care plans and includes `training in the areas of disability, sensory impairment, challenging behaviour and epilepsy. We know this from the feedback given from staff who completed surveys and from records seen on the day of inspection. Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Comprehensive risk assessments must be in place to ensure people using the service are protected from identified risks. Care plans are comprehensive but could be simplified and written in a way, which captures the person’s individuality. EVIDENCE: One care plan was inspected and it was noted that this had recently been reviewed. Reviews are completed every six months. The care plan inspected gave information about the person’s health and support needs but did not give any social history, significant life events or important memories/occasions. This was discussed with the manager at the time of the inspection. The Deputy Regional Director stated in her response to the draft inspection report that. Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 11 ‘All our deaf blind people have ‘Life’ books which capture family histories, significant events etc. these are constantly updated for each person with their Designated Social Tutor. All are kept at the house and the pictures/information is used to enable service users to create displays which are hung on the walls of the house.’ The plan detailed what the person could do for themselves and what they needed assistance with but did not include information about the persons preferred routine of daily living. There was no evidence that the resident had been involved in the recent review of the plan. The Deputy Regional Director stated in her response to the draft inspection report that. ‘With regard to people’s preferred routines, we of course support a range of deaf blind people with varying levels of comprehension and communication skills. Strategies are devised by our staff who are trained in specific communication skills to work with our people to understand and encourage them to express their preferences related to all aspects of their lives, this information is passed between House and Resource Centre. A copy is contained in the care plans. The care plan also included details of behavioural guidelines. These were very detailed and stated that a multi disciplinary team had drawn them up, evidence of this was not provided as the guidelines had not been signed by anyone from health or social services. SENSE employ a regional behaviour specialist who provides training based on a non-aversive framework and staff receive training on non-violent crisis intervention. Staff are expected to read and adhere to procedures in place. We were concerned that the care plans and other guidance are not easy to read as they are lengthy and do not clearly describe how to meet a person’s needs. The Deputy Regional Director stated in her response to the draft report that ‘The behaviour guidelines are created by the specialist behaviour consultant employed by SENSE’ and stated ‘Our deaf blind people are placed by health and/or social services department’s. There is very little guidance from those statutory agencies related to behaviour guidelines, it is the knowledge and expertise of the SENSE specialist that identifies the strategies and supports the work of the staff. All the information is shared between line manager and support staff and the workers reads and signs that they have read the strategies. Any changes in the programmes are subject to the same procedure. In my opinion it may be difficult to gain a Health/Social Care signature for them as these agencies are not the instigators and are usually generic Care Managers who have commissioned the placement with little knowledge of this area of expertise.’ Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 12 There was no risk assessment on this file looking at activities of daily living. Another file was inspected and there were risk assessments in place. These had not been updated and some of the information was unsafe, because it did not fully explore the risks or the action staff must take to minimise the risks. A requirement has been made and a serious concern letter was sent to the manager following the inspection. Some action was taken to rectify this at the time of the inspection and following the serious concern letter, the manager sent through updated and robust risk assessments for the people identified. A separate risk assessment was seen for people using the minibus. In addition staff carry identification badges when out in public. Staff receive additional training before they can drive the minibus independently. Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Residents are enabled to live full and active lives. EVIDENCE: On the day of inspection residents were out with the exception of one person who was being supported by staff. A range of activities are provided and people go out to a further education resource centre in Peterborough. They are encouraged to develop important life skills and be as independent as possible. Goals are set and six monthly reviews incorporate both the resource centre and the home who work together to ensure people reach their full potential. Other agencies are involved where their input is identified through an unmet or changing need. Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 14 Information from the AQAA and self-assessment report stated that evening and weekend activities are planned according to the wishes of the residents. Residents are encouraged to be involved in the running of the home. They are involved in holidays (for which SENSE has a budget,) meal planning and domestic chores. Staff recognise each persons communication needs and information is made accessible where possible. The manager said that residents are encouraged to maintain contact with family members who visit the home and participate in reviews. A number of relatives who completed surveys were satisfied with the service. The staffing rotas showed that there are enough staff on duty. Many of the residents have mobility issues or require support due to sensory impairments. The service has a minibus to take people out. There are limitations in using public transport and this may curtail one to one activities at times. One survey completed by a person using the service stated that they had freedom and were able to access the garden and had good health and social care support. Menu records are kept and menus are planned on a four-week cycle. Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Residents health care needs are met at the home. EVIDENCE: Health care needs are recorded and staff receive training and support to assist them in meeting peoples’ needs in a dignified and respectful way. The AQAA and Self- assessment report make numerous references and evidence of how they promote equality and diversity within their service. Health care records are recorded in a health care plan. These are currently being updated. Sense has produced a national document, which includes more information. On the plan inspected using the old format some information was missing. Record of weights was missing. There was no recorded evidence of well woman’s health, or dental services. There was no specific intervention re the management of anxiety. Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 16 Management of anxiety is undertaken through the behaviour guidelines created via our Behaviour Consultant, he creates graphs and plots the cycles of behaviour for every individual. This is shared with the staff, who again, are required to read and sign to that effect.’ The Deputy regional director stated that. ‘Weight loss is plotted and concerns raised in visits to the GP and if appropriate to other professionals. A nutritionist would be requested via the GP and the staff would be pro-active in supporting this course of action.’ All is recorded in the medical file. This would be done in consultation with the Behaviour Specialist to ensure that any links may be made.’ For the record inspected evidence of the above was not found. The Deputy Regional Director stated in her response to the draft report that ‘Every service user has a medical file which is held at their house, all consultations with a range of professionals are included, as is all correspondence related to every aspect of health, well being and dental services. We undertake regular visits with our deafblind people to dental and health services and in 37 Redgate, we undertake those above and beyond the regular 6 monthly checks. SENSE has additionally entered into discussions with the Commissioners in Lincs PCT to identify a model of preventative oral hygiene. Once agreed, this will be rolled out across the region.’ No one using the service currently administers his or her medication. Staff are trained in the use of rectal administration and there is a generic policy in place. Individual protocols must be drawn up for individuals, within a multi agency framework and consent sough from the individual, next of kin or advocate. The Deputy Regional Director stated in her response to the draft report ‘It is difficult for the people that we support to give permission for administration of medication, however, we continue to work towards enabling our service users to be pro-active in decision making etc wherever possible.’ One medication administration record (MAR) sheet was inspected and was satisfactory. Staff administer medication in pairs as a safety measure. Staff are observed giving out medication until they are deemed competent. Questionnaires are used to test staff knowledge and they have to complete refresher courses. The manager and deputy have completed advanced courses in the safe administration of medication. The manager stated policies are in place for homely remedies The Deputy Regional Director stated in her response to the draft report ‘There are guidelines for all the staff to follow with regard to administration of medication, the House Manager has also interpreted the guidelines for each specific deafblind person with strategies for alternatives if oral administration is not possible. All the information is held in the medication folder with the drugs trolley and each individual has their own section in this related to their needs. Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 17 Staff also undertake an annual refresher for medication. This includes administrating medication rectally where appropriate. ‘ This was not seen at the time of the inspection, although discussed and requested. The last wishes of people using the service were not recorded on the file inspected, but the manager stated this information had been requested from families. Evidence of this was provided. The Deputy Regional Director stated in her response to the draft report. ‘ For most of our deafblind people, their last wishes, expressed by family or nearest relative are documented, we do find however that some of our families are reluctant to engage with this discussion, nevertheless SENSE undertakes to raise this at reviews and other meetings in order that the information is recorded. Additionally SENSE has a written record in each person’s file of information related to their ethnic origin and any special request related to that in the event of death. ‘ Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Guidance on adult protection is not consistent thereby potentially putting residents are risk. EVIDENCE: The manager stated that a suitably qualified person completes the majority of the training provided to staff. A training matrix identifies when staff need to complete their training by, including refresher training. The manager was asked for the adult protection procedures. The copy in the office was quite dated and some of the guidance was poor. The home did not have a copy of the local safeguarding adults protocol and guidance. The complaints procedure was satisfactory Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People living at the home have accommodation provided which is of a high standard and adapted to meet their needs. EVIDENCE: The home is situated near the community centre and local shops. One person is able to go regularly to the shops unescorted. Security has been an issue in the past and security cameras are in place. Accommodation is sufficiently spacious and each resident has their own bedroom. There are shared communal areas including a large open plan lounge/dining and kitchen area. Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 20 A requirement made at the last inspection regarding the environment had been fully met. The decorators were at the home on the day of inspection and a number of bedrooms were being decorated. The lounge and utility room had been completed. The home was clean and well maintained throughout. The bathroom near the office on the first floor was very sparse and uninviting. The manager confirmed that this was still in use. . ‘The bathroom is scheduled for complete replacement/refurbishment as I believe the Inspector was informed, this will be completed with urgency. ‘ Specialist equipment and aids are provided where identified and the house is accessible. Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Staff work in a well planned and well managed service, which supports them through good induction and training. EVIDENCE: We spoke with one member of staff, the manager and deputy. The member of care staff confirmed that they had received both general training and specialist training to help meet the needs of deaf blind people. They stated they had completed challenging behaviour, physical intervention, coaching skills, working with families, sexual awareness, medication, autism, visual awareness, epilepsy and experiencing disability, which is a practical day, exploring what if feels like to have a visual or physical impairment. Staff complete an induction folder and work sheets, which include questions, and answers and quizzes. No one has completed a risk assessment course. A requirement has been made. Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 22 The staff member confirmed that they completed a number of observational shifts and had a probationary interview. They confirmed that they received regular supervision and appraisal. The staff member was asked about morale and they stated that there is good teamwork and the team meet regularly. There is a key worker system but care staff do not write care plans, but make a contribution through the daily notes and the communication book. Two staff files were inspected and contained all the relevant documentation. There was no staff photograph on one, but there were two forms of picture identification. Criminal records checks are kept on file and these are updated every three years for staff. This is good practice. Staff identification badges are also updated annually. The staffing rota was inspected and was fine but did not include surnames of staff. These must be included. The Deputy Regional Director stated in her response to the draft report. ‘The staff rota is devised with an accompanying list of the full names and contact details of the whole staff team. It is also colour coded so that anyone at a glance can understand the reason why a member of staff may not be undertaking that shift, the name of the replacement worker is added here too. We believe this more than meets the requirements of the Care Standards. ‘ Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40 41,42 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The home regularly reviews its performance so that residents receive a good service. EVIDENCE: The home completed a self-assessment report in November 2007. Scoring for all questions answered by parents and advocates ranged from Excellent 47 , good, 28 ok, 13 poor 3 and don’t know/know response 11 . Action plans have been put into place where shortfalls have been identified. The manager has been in post since October 2006 and initially worked without a senior management team. This has been addressed and there is now a Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 24 strong team: deputy manager and two team leaders. The manager has many years experience, twelve years have been working for SENSE. 37 and 38 Redgate Court are both registered services. Staff work separately in the homes, but the managers of each respective service work alternative weekends so there is always a management presence. An on call system is in operation. A number of policies were requested during the inspection. These were supplied but many had been written some years ago and were wordy documents, which did not always give good guidance. The manager stated that polices are updated regularly and these are on the intranet and key policies are printed off for staff. Staff do not have access to the intranet and it was unclear how easily relatives or people using the service were able to access policies if required, other than the service user guide and statement of purpose. These were not readily accessible for everyone using the service. One person’s financial records were inspected and were clearly recorded and the balance was accurate. Records relating to fire safety and water temperatures were checked and were satisfactory. The service had separate fire risk assessments for the building and for individuals, assessing what their actual or likely reaction would be to the fire alarms and what action should be taken. It was not clear what the protocol at night would be given that night staff work between houses. This should be made explicit. The service has not had recent inspections for fire prevention services or environment health services. The record of fridge freezer temperatures indicated the fridge temperatures were too high and no corrective action was recorded. The manager was asked to put something in place to ensure staff knew what the temperature should be and what actions they should take if not correct. The Deputy Regional Director stated in her response to the draft report. ‘A protocol is in place for night staff levels between houses and the Area Manager has informed CSCI of this in the past. Fire Risk Assessment for each individual is in place and held on the Fire Safety File. The local Fire Service have been requested to visit, however we are informed by them that they are satisfied with the SENSE fire safety assessments and precautions and that they will not necessarily visit within a specific period. ‘ The manager asked if it was acceptable to remove a sink in one of the bedrooms given the risks it posed to the individual. Health and safety is paramount and a risk assessment should be drawn up explaining the homes actions. Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 1 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 3 3 x 3 3 3 3 X Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15(1) Requirement Timescale for action 30/04/08 2 YA9 3 YA19 4 YA20 Care plans must be more detailed so that they accurately reflect residents’ needs. 13(4)(a)(b)(c) Risk assessments must be 06/02/08 comprehensive and regularly reviewed regularly so that residents are safe. 17(1)(a) The home must keep accurate 30/04/08 records of a person’s weight and draw up a plan of action to manage severe weight loss in consultation with relevant specialists and the dietician. A nutritional assessment must be undertaken. 13(2) Individual protocols for the 30/04/08 administration of medication administered rectally must be drawn up. 13(6) Up to date information regarding adult protection must be available to staff. 30/04/08 5 YA23 Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Redgate Court (37) DS0000015129.V359556.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Inspection Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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